Health Equity & Social Determinants

Transcription

1 Health Equity & Social Determinants Overview Professor Tony Blakely, University of Otago 1 Index

2 Preliminaries Acknowledgements and conference pack Acknowledgements: NZMA and University of Otago teams Co-funding New Zealand College of Public Health Medicine Public Health Association Prior Centre Conference Pack: Power points of all presentations NZMA Equity Statement Fact and Action sheets Other 2

3 Structure Purposes of today Background: Health inequality facts and trends in New Zealand Policy actions in recent decades Frameworks and perspectives: What is health inequity? Early childhood and life-course current examples Universalism targeting, and progressive universalism But can we afford equity?. joining up current agendas Where to next for Aotearoa New Zealand?: A possible top-ten list A few specific comments from myself (aka my 7 slides) Risk factors (e.g. smoking) Health services and changing drivers of inequalities 3

4 Purposes of today 1. To sustain and enhance a focus on health inequities. 2. To learn from the English and WHO experience, and assess what might be applicable to New Zealand. 3. To explore visions and objectives for next steps to address health inequalities in New Zealand. We have included a list of next best 10 actions to take on reducing inequities in health in New Zealand in your conference pack please consider it, debate it (e.g. during panel session), and improve it (e.g. submit your improvements to 4

5 Life expectancy trends by ethnicity The last 60 years Non-Māori Male Māori Male Non-Māori Female Māori Female 5

6 Life expectancy trends by ethnicity The last 130 years Non-Māori Male 40 Non-Māori Female 30 Māori Male 20 Māori Female Source: Woodward and Blakely, History of Life Expectancy in New Zealand, work in progress 6

7 Causes of death driving ethnic ineq CVD most important, but over time; cancer 7

8 Socioeconomic mortality inequalities Parallel tracking constant absolute, but relative ineq Mostly parallel tracking in absolute terms 30% and 41% decreases for low and high income males, respectively 27% and 37% decreases for low and high income females, respectively 8

9 NZ used to have lowest child mortality Similar pattern females, 1-5 yrs, 5-14 yrs, 15-24yrs 1 <1 year old males Australia Canada 0.1 Denmark Eng & Wales Finland Norway 0.01 NZ Māori NZ non-m s 1880s 1900s 1920s 1940s 1960s 1980s 2000s Scotland Sweden Source: Woodward and Blakely, History of Life Expectancy in New Zealand, work in progress. [Primary source; Human Mortality Database.] 9

10 NZ used to have lowest child mortality Could our high child poverty rates be part of the reason? Source: MSD (2010) Household incomes in New Zealand. Cited in: Gleisner et al. Working Towards Higher Living Standards for New Zealanders. New Zealand Treasury 10

11 Young mortality inequalities worrying Little if any improvement in low income, yrs 11

12 What have we/nz done about it? 1-5 Quite a bit in recent decades mostly around process 1. Income inequality reduced slightly in the 2000 s - but is perhaps now increasing again 2. Social welfare policies have been implemented - E.g. Working for Families (at least partially) pro-equity 3. Intersectoral activities implemented - E.g. retrofitting and insulation of housing stock (energy efficiency and health benefits) 4. Māori health provider, and Māori development more generally, has been strong: - E.g. ToW and Māori health in Public Health & Disability Act. 5. Increasing focus on the specific needs of Pacific 12

13 What have we/nz done about it? 6-10 Quite a bit in recent decades mostly around process 6. Many policies include equity has flowed through into programmes, research, health professional training (e.g. cultural competency), and use of health equity impact tools (e.g. HEAT). 7. Funding of health services by deprivation & ethnicity 8. Tailored health promotion and service delivery E.g. Māori language messages in tobacco control 9. Research and monitoring on health inequalities has improved our understanding and allowed tracking 10.Targets and performance indicators routinely include metrics by ethnicity and deprivation. 13

14 Structure Purposes of today Background: Health inequality facts and trends in New Zealand Policy actions in recent decades Frameworks and perspectives: What is health inequity? Early childhood and life-course Universalism targeting, and progressive universalism But can we afford equity?. joining up current agendas Where to next for Aotearoa New Zealand?: A possible top-ten list A few specific comments from myself (aka my 7 slides) Risk factors (e.g. smoking) Health services and changing drivers of inequalities 14

15 What is an inequity in health? Guiding principles, but still tricky to decide Whitehead s 7 determinants of health inequalities/differences: 1. Natural, biological variation. 2. Health-damaging behaviour if freely chosen (e.g. risky sports). 3. Transient health advantage of one group over another, due to one group adopting healthier practises earlier. 4. Health damaging behaviour where the choice of lifestyles is severely limited. 5. Exposure to unhealthy, stressful living and working conditions. 6. Inadequate access to essential health and other public services. 7. Natural selection of health-related social mobility, involving the tendency for sick people to move down the social scale. 15

16 Early childhood and lifecourse Research boom basis for evidence-based policy Two recent reports: PM s Chief Science Advisor ECE Taskforce Highlight relevant issues for today: Evidence on interventions Efficiency Universalism vs targeting Pro-equity vs inequity increasing programmes Quality An Agenda for Amazing Children 16

17 Intervening early pays off Universal & targeting required; progressive universalism Structured, quality programmes in early childhood have long-reaching pay offs But a lot of programmes not evidence based, not effective, and possibly even harmful reprioritisation needed Potential to be pro-equity: School-based education programmes on drugs tend to be most effective in low risk children. but targeted home visiting & parental skills programmes benefit disadvantaged. High quality early childhood education can be most effective among disadvantaged (Dearing et al (2009) Child Development) Although all children gain from quality early childhood education, society benefits most from the investment in children from low-income or disadvantaged homes (p.15, Improving the Transition) 17

18 But childhood focus no panacea! Context and period effects latter in life matter Consider alcohol: Early child programmes and (well conducted) school education programmes may reduce individuals alcohol harm in adolescence and older But population-wide programmes (e.g. pricing, availability) reduce overall harm, and inequalities, much more effectively Consider cardiovascular disease: Has some causal antecedents in childhood But population rates peaked in 1970, and have fallen 80% since, for all age groups, indicating importance of population-wide changes effecting all age groups (i.e. period effects as opposed to cohort effects). 18

19 Can we afford reducing health inequity? Yes social investment with major paybacks Cost effectiveness: - Generally agreed that better quality early childhood interventions return up to $10 to $20 per $1 invested - Public health prevention programmes especially population-wide ones such as alcohol tax, salt reformulation in foods cost saving and likely pro-equity (Vos et al, ACE-Prevention, 2010) Redistribution of societal investment is possible: - For example, consider welfare benefits. 19

20 Benefit expenditure over time By far and away the biggest benefit is superannuation $14,000,000 $12,000,000 $10,000,000 'Other' Superannuation $8,000,000 $6,000,000 $4,000,000 $2,000,000 $ Carer s benefits Invalid s Benefits Sickness-related Benefits Unemploymentassociated Benefits Source: MSD (2010) The Statistical Report [Note: excludes Working for Families, which in 2008 was about: $2.6 million tax credits; $0.85 million accommodation supplements; $0.15 childcare assistance.] 20

21 Yet we tolerate high child poverty 21

22 Increasing age of super entitlement Seems only fair, and will free up resources Age of entitlement set at 65 yrs in Since then life expectancy has increased by about 25 years! Other OECD countries increasing age of entitlement. We should too, so long as living standards of people who cannot work >65 yr are protected E.g. by having Invalid s benefit and indeed all Benefits including Superannuation set at an income necessary for healthy living (a.k.a. Minimum Income for Healthy Living as recommended in Marmot Review) Such redistribution within Welfare would allow shifting of resources to address child poverty. 22

23 Structure Purposes of today Background: Health inequality facts and trends in New Zealand Policy actions in recent decades Frameworks and perspectives: What is health inequity? Early childhood and life-course Universalism targeting, and progressive universalism But can we afford equity?. joining up current agendas Where to next for Aotearoa New Zealand?: A possible top-ten list A few specific comments from myself (aka my 7 slides) Risk factors (e.g. smoking) Health services and changing drivers of inequalities 23

24 What to do next? Lets debate, improve and then try to act on this list 1. Equitable and fair fiscal and social welfare policy 2. Maintain and enhance social cohesion 3. Maintaining and enhancing investment in early childhood. 4. Aligning climate change, sustainability and pro-equity policies 5. Health equity needs to be widely understood 6. Ill-health prevention that addresses risk factors 7. Ensuring fair employment and safe and healthy workplaces 8. Maintaining and enhancing Māori, Pacific and Asian policies and programmes 9. Ensuring health services are equitable 10. Health equity research to continue and focus on what works. Blakely T, Simmers D, Sharpe N. Inequities in health and the Marmot Symposia: time for a stocktake. NZ Med J, 8 July 2011 Fact and Action Sheets in your conference pack 24

25 Health care matters Treatments improve + costs escalate = inequities likely Consider that: Half of the huge reductions in CVD mortality in last 30 years due to improved treatments Cancer mortality gaps slowly opening up, and survival worse for Māori (and to some extent lower socio-economic groups) Which makes an equity focus important in: prioritisation of health resources (new National Health Committee) quality of services (Health Quality and Safety Commission) information systems: recall systems that stop people falling between the gaps for monitoring and research 25

26 Estimating LE by ethnicity in 2040 Tobacco control eradication matters If we go smokefree (compared to 2006 smoking rates continuing unchanged into the future), we estimate that by 2040: an additional 5 year gain in life expectancy for Māori an additional 3 year gain for non-māori and therefore a 2 year closing in ethnic inequalities in life expectancy Making New Zealand smoke-free is achievable, and worthwhile Blakely T, Carter K, Wilson N, et al. If nobody smoked tobacco in New Zealand from 2020 onwards, what effect would this have on ethnic inequalities in life expectancy? NZ Med J 2010;123(1320):

27 20/20 vision on 2040 Visioning the end of Māori-nonMāori inequalities in LE 90 Non-Mäori (SNZ) Male 80 Non-Mäori (SNZ) Female Māori pre WWII Male 70 Māori pre WWII Female 60 Mäori (SNZ) Male Tobacco eradication is perhaps the single most important thing to do to achieve an end to ethnic inequalities in health Mäori (SNZ) Female Māori (correcting for undercount) Male Māori (correcting for undercount) Female Projected non-māori 2.0% Male Projected non-māori 2.0% Female Projected non-māori 3.5% Male Projected non-māori 3.5% Female 27

28 Back up slides 28

29 Infectious diseases A resurgent source of inequalities Rheumatic fever very high by international standards among Pacific and Māori approximately 40 and 20 times the European/Other rates respectively. Rheumatic fever is associated with crowding and poverty, and is usually rare in rich countries these days. Close contact communicable disease hospitalisation rates not falling over time, and much higher for Māori and Pacific (Baker et al, in progress) 29

30 Rheumatic fever rates Perhaps the most prominent health inequality at moment Index admissions pe er 100, Pacific Māori European/Other Richard Milne, Diana Lennon et al., University of Auckland,

31 Suicide rates by ethnicity High youth and Māori rates 31

32 CVD mortality rates by ethnicity 32 Index

33 35-69 yrs, CVD mortality, Australia 33 Index

34 Suicide and injury death rates by ethnicity 34